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Background External validation is essential before implementing a predictive model in clinical practice. This analysis validated the performance of the ACUITY/HORIZON risk score in the most contemporary Thai PCI registry. Methods The ACUITY/HORIZON model was applied and validated externally in 12,268 ACS (acute coronary syndrome) patients. For revision and updating models, the regression coefficientd of all predictors were re-estimated and then additional predictors were stepwise selected from multivariate analysis. Results In-hospital bleeding defined by the BARC (Bleeding Academic Research Consortium) criteria was 1.3% (161 patients) and 2.3% (285 patients) by the ACUITY criteria. The calibration of both scales demonstrated overestimation of the original model with C-statistic values of 0.704 for ACUITY major bleeding and 0.793 for BARC 3 or 5 bleeding. For ACUITY major bleeding, the discriminatory power of the update model improved substantially when congestive heart failure (CHF), prior vascular disease as well as body mass index were considered. The update model demonstrated good calibration and C-statistic of 0.747 and 0.745 with no white blood cell (WBC) count. For BARC 3 or 5 bleeding, good calibration and discriminatory capacity could be observed when CHF and prior vascular disease were added in the update models, with an excellent C-statistic of 0.838, and a lower C-statistic value of 0.835 was obtained in the absence of WBC count. Conclusion The ACUITY/HORIZON score was successfully validated in contemporary predictive and risk-adjustment models for PCI-related bleeding. The update models had good operating characteristics in patients from a real-world ACS population irrespective of bleeding definitions.

Background. Percutaneous coronary intervention (PCI) practice and outcomes vary substantially in different parts of the world. The contemporary data of PCI in Asia are limited and only available from developed Asian countries. Objectives. To explore the pattern of practice and results of PCI procedures in Thailand as well as a temporal change of PCI practice over time compared with the registry from other countries. Methods. Thai PCI Registry is a prospective nationwide registry that was an initiative of the Cardiac Intervention Association of Thailand (CIAT). All cardiac catheterization laboratories in Thailand were invited to participate during 2018-2019, and consecutive PCI patients were enrolled and followed up for 1 year. Patient baseline characteristics, procedural details, equipment and medication use, outcomes, and complications were recorded. Results. Among the 39 hospitals participated, there were 22,741 patients included in this registry. Their mean age (standard deviation) was 64.2 (11.7) years and about 70% were males. The most common presentation was acute coronary syndrome (57%) with a high proportion of ST-elevation myocardial infarction (28%). Nearly two-thirds of patients had multivessel disease and significant left main stenosis was reported in 11%. The transradial approach was used in 44.2%. The procedural success rate was very high (95.2%) despite the high complexity of the lesions (56.9% type C lesion). The incidence of procedural complications was 5.3% and in-hospital mortality was 2.8%. Conclusion. Thai PCI Registry provides further insights into the current practice and outcomes of PCI in Southeast Asia. The success rate was very high, and the complications were very low despite the high complexity of the treated lesions.

To determine the risk prediction of various degrees of impaired renal function on all-cause mortality in patients following percutaneous coronary intervention (PCI).Patients with chronic kidney disease (CKD) are at high risk of all-cause mortality after PCI. However, there are less data of various degrees of impaired renal function to predict those risks.This was a subgroup analysis of nationwide PCI registry of 22 045 patients. Patients were classified into six CKD stages according to preprocedure estimated glomerular filtration rate (eGFR) (ml/min/1.73 mPatients with CKD stage I-V without and with on dialysis were found in 26.9%, 40.8%, 23.2%, 3.9%, 1.5%, and 3.7%, respectively. PCI procedural success and complication rates ranged from 94.0% to 96.2% and 2.8% to 6.1%, respectively. One-year overall survival among CKD stages I-V was 96.3%, 93.1%, 84.4%, 65.2%, 68.0%, and 69.4%, respectively (p .001 by log-rank test). After adjusting covariables, the hazard ratios of all-cause mortality for CKD stages II-V as compared to stage I by multivariate Cox regression analysis were 1.5, 2.6, 5.3, 5.9, and 7.0, respectively, (p .001).Among patients undergoing PCI, lower preprocedure eGFR is associated in a dose-dependent effect with decreased 1-year survival. This finding may be useful for risk classification and to guide decision-making.

To establish national diagnostic reference levels (DRLs) for percutaneous coronary intervention (PCI) in Thailand for lesions of different complexity.Radiation dose quantity as kerma-area-product (KAP) and cumulative air-kerma at reference point (CAK) from 76 catheterization labs in 38 hospitals in PCI registry of Thailand was transferred online to central data management. Sixteen months data (May 2018 to August 2019) was analyzed. We also investigated role of different factors that influence radiation dose the most.Analysis of 22,737 PCIs resulted in national DRLs for PCI of 91.3 Gy.cmThis large multi-centric study established DRLs for PCIs which can act as reference for future studies. A hallmark of our study is establishment of reference levels for coronary lesions classified as per ACC/AHA and thus for different complexities.

The impact of the adherence to the adjunctive use criteria (AUC) for intravascular ultrasound (IVUS) guided percutaneous coronary intervention (PCI) and clinical outcomes in low IVUS volume countries are limited. The current study compared the procedural success and complication rates between used and not used IVUS catheter in the patients who were met (C +) and were not met (C−) the AUC for IVUS-guided PCI. From June 2018 through June 2019, a total of 21,066 patients were included in the Thai PCI registry. Among the study population, 15,966 patients (75.8%) have met the IVUS-AUC. The IVUS-guided PCI rates were 14.5% and 11.3% in the C + and C − groups, respectively. After adjusting for covariables by propensity model, IVUS-guided PCI was identified as an independent predictor of the procedural success rate regardless of whether the AUC were met with the relative risk [RR (95% confidence interval (CI)] of 1.033(1.026–1.040) and 1.012(1.002–1.021) in C + and C− groups, respectively. IVUS-guided PCI increased the procedural complication risks in both groups but were not significant with corresponding RRs of 1.171(0.915–1.426) and 1.693(0.959–2.426). Procedural success was achieved with IVUS-guided PCI regardless of whether the AUC were met. IVUS-guided PCI did not lead to an increase in procedural complications.

Background“Smoker's paradox” is a controversial phenomenon that describes an unexpectedly favorable short-term outcome of smokers post-percutaneous coronary intervention (PCI). This study aimed to evaluate the effect of smoking status on recurrent major adverse cardiovascular events (MACEs) in patients who recently underwent PCI and to determine whether it was paradoxical.MethodsThis study utilized data from the nationwide Thai PCI registry, enrolling patients during 2018–2019. Our study factor was smoking status, classified as current smokers, ex-smokers, and nonsmokers. The outcome of interest was the time to occurrence of a composite of MACEs (i.e., all-cause death, myocardial infarction (MI), stroke, and unplanned revascularization) evaluated at about 1-year post-PCI. A propensity score (PS) model using inverse probability weighting with regression adjustment was used to estimate the effect of smoking on the occurrence of MACE.ResultsCurrent smokers, ex-smokers, and non-smokers accounted for 23, 32, and 45% of the 22,741 subjects, respectively. Smokers were younger, more frequently male, and had fewer traditional atherosclerotic risk factors. Current smokers presented more frequently with ST-elevation MIs (STEMIs) and cardiogenic shock (54 and 14.6%, respectively) than non-smokers. MACE rates were 1.9, 1.2, and 1.6 per 100 patients per month in the current smokers, ex-smokers, and non-smokers, respectively. After applying a PS, patients with a history of current smoking and ex-smoking developed the onset of recurrent MACEs significantly sooner than non-smokers, with a median time of 4.4 vs. 4.9 vs. 13.5 months (p < 0.001), respectively.Conclusions“Smoker's paradox” was not observed in our patient population. Current smokers and ex-smokers were prone to develop an earlier onset of a post-PCI MACEs than nonsmokers and need a smoke cessation program for further prevention.

Background: Little is known regarding the impact of socioeconomic factors on the use of evidence-based therapies and outcomes in patients with heart failure with reduced ejection fraction across Asia. Methods: We investigated the association of both patient-level (household income, education levels) and country-level (regional income level by World Bank classification, income disparity by Gini index) socioeconomic indicators on use of guideline-directed therapy and clinical outcomes (composite of 1-year mortality or HF hospitalization, quality of life) in the prospective multinational ASIAN-HF study (Asian Sudden Cardiac Death in Heart Failure). Results: Among 4540 patients (mean age: 60±13 years, 23% women) with heart failure with reduced ejection fraction, 39% lived in low-income regions; 34% in regions with high-income disparity (Gini ≥42.8%); 64.4% had low monthly household income (P interaction Conclusions: These findings highlight the importance of socioeconomic determinants among patients with heart failure in Asia and suggest that attention should be paid to address disparities in access to care among the poor and less educated, including those from wealthy regions. Registration: URL: https://clinicaltrials.gov ; Unique Identifier: NCT01633398.

Objectives The impact of the COVID-19 pandemic on the treatment of patient with aortic valve stenosis is unknown and there is uncertainty on the optimal strategies in managing these patients. Methods This study is supported and endorsed by the Asia Pacific Society of Interventional Cardiology. Due to the inability to have face to face discussions during the pandemic, an online survey was performed by inviting key opinion leaders (cardiac surgeon/interventional cardiologist/echocardiologist) in the field of transcatheter aortic valve implantation (TAVI) in Asia to participate. The answers to a series of questions pertaining to the impact of COVID-19 on TAVI were collected and analyzed. These led subsequently to an expert consensus recommendation on the conduct of TAVI during the pandemic. Results The COVID-19 pandemic had resulted in a 25% (10-80) reduction of case volume and 53% of operators required triaging to manage their patients with severe aortic stenosis. The two most important parameters used to triage were symptoms and valve area. Periprocedural changes included the introduction of teleconsultation, preprocedure COVID-19 testing, optimization of protests, and catheterization laboratory set up. In addition, length of stay was reduced from a mean of 4.4 to 4 days. Conclusion The COVID-19 pandemic has impacted on the delivery of TAVI services to patients in Asia. This expert recommendation on best practices may be a useful guide to help TAVI teams during this period until a COVID-19 vaccine becomes widely available.

summary Background: Little is known about the epidemiology of the elderly who receive cardiopulmonary resuscitation (CPR) and the subsequent survival factors in Thailand and other developing countries. The objective of this study was to determine the rate of CPR and the survival rate among hospitalized Thai elderly patients, and also factors predicting survival at discharge. Methods: National databases from three sources were searched. These three systems accounted for 96% of the Thai population. All inpatients in the fiscal year 2010 (from October 1, 2009 to September 31, 2010) aged 60 years or over who received CPR procedure were included. Baseline characteristics were studied. The study outcomes were CPR rate, mortality rate, and survival factors. Results: In total, 17,813 elderly patients who were hospitalized during the 2010 fiscal year received CPR (997.2/100,000 older adults). Of those, 5125 patients (28.77%) survived at discharge. Pre-existing comorbidity, asystole, time on a mechanical ventilator > 96 hours, and being admitted to a private hospital were associated with poorer outcomes (p < 0.05). Conclusion: The rate of CPR in hospitalized elderly patients was 997.2 events/100,000 older adults with a survival rate of 28.77%. Factors predicting death at discharge are pre-existing comorbidities, cardiac arrhythmia type, intervention/procedure, and type of hospital.

To diagnose the cause of pulmonary hypertension is sometimes challenging and may require interventional and advance imaging procedures. A 70-year-old male presented with progressive dyspnea and edema for several months. He had been stabbed at back and undergone kidney surgery in the past. Physical

Background— Mitral annuloplasty is the most common surgical procedure performed for ischemic mitral regurgitation (MR). Surgical mitral annuloplasty is limited by morbidity, mortality, and MR recurrence. We evaluated the safety and feasibility of a transvenous catheter-delivered implantable device to provide a percutaneous alternative to surgical mitral annuloplasty. Methods and Results— Five patients with chronic ischemic MR underwent percutaneous transvenous implantation of an annuloplasty device in the coronary sinus. Implantation was successful in 4 patients. Baseline MR in the entire group was grade 3.0±0.7 and was reduced to grade 1.6±1.1 at the last postimplantation visit when the device was intact or the last postprocedural visit in the patient in whom the device was not successfully implanted. Separation of the bridge section of the device occurred in 3 of 4 implanted devices and was detected at 28 to 81 days after implantation. There were no postprocedural device-related complications. Conclusions— Percutaneous implantation of a device intended to remodel the mitral annulus is feasible. Initial experience suggests a possible favorable effect on MR. Percutaneous transvenous mitral annuloplasty warrants further evaluation as a less invasive alternative to surgical annuloplasty.

Background— Percutaneous aortic valve implantation by an antegrade transvenous approach has been described but is problematic. Retrograde prosthetic aortic valve implantation via the femoral artery has potential advantages. Percutaneous prosthetic aortic valve implantation via the femoral arterial approach is described and the initial experience reported. Methods and Results— The valve prosthesis is constructed from a stainless steel stent with an attached trileaflet equine pericardial valve and a fabric cuff. After routine aortic balloon valvuloplasty, a 22F or 24F sheath is advanced from the femoral artery to the aorta. A steerable, deflectable catheter facilitates manipulation of the prosthesis around the aortic arch and through the stenotic valve. Rapid ventricular pacing is used to reduce cardiac output while the delivery balloon is inflated to deploy the prosthesis within the annulus. Percutaneous aortic prosthetic valve implantation was attempted in 18 patients (aged 81±6 years) in whom surgical risk was deemed excessive because of comorbidities. Iliac arterial injury, seen in the first 2 patients, did not recur after improvement in screening and access site management. Implantation was successful in 14 patients. After successful implantation, the aortic valve area increased from 0.6±0.2 to 1.6±0.4 cm 2 . There were no intraprocedural deaths. At follow-up of 75±55 days, 16 patients (89%) remained alive. Conclusions— This initial experience suggests that percutaneous transarterial aortic valve implantation is feasible in selected high-risk patients with satisfactory short-term outcomes.

Background: Paravalvular leaks (PVLs) are a well-recognized complication of prosthetic valve replacement. Most are asymptomatic and benign, but some may cause symptoms due to a large regurgitant volume or hemolysis. Medical therapy is palliative, while reoperation carries significant morbidity and mortality. Percutaneous transcatheter closure techniques, now routinely applied in the management of pathological cardiac and vascular communications, may be adaptable to PVL closure, potentially offer symptomatic relief. Methods: We reviewed our experience with attempted percutaneous closure of PVLs, using data from medical and procedural records. Results: Between 2001 and 2004, 14 procedures were performed in 10 patients, all under general anesthesia, with transesophageal and radiographic guidance. Mitral (9) and aortic (1) valve replacements were involved, both mechanical and bioprosthetic. A variety of devices were used, including atrial septal occluders, patent ductus arteriosus occluders, and coils (all of label use). Six had a single procedure, which was technically successful in four: in two, the PVL could not be crossed. Four underwent a second procedure, which was technically successful in three; in one the previously deployed device was dislodged necessitating urgent, but ultimately uneventful, surgical removal and leak repair. One patient had transient severe hemolysis, which resolved after 1 week. At 1-year follow-up (9/10 pts) three had died, five had sustained symptomatic improvement while 1 patient with a residual leak still required regular blood transfusions. Conclusions: Percutaneous closure of PVLs is time-consuming but feasible in selected patients, with a reasonable degree of technical and clinical success. A second procedure may be necessary and a variety of complications can occur. © 2006 Wiley-Liss, Inc.

The appropriate management of patients with mitral regurgitation (MR) and left ventricular dysfunction (LVD) is controversial. The study aim was to determine whether the presence of contractile reserve (CR) assessed by dobutamine stress echocardiography (DSE) was associated with improved outcomes.Death and heart transplantation were analyzed as the primary outcomes associated with the presence of CR. A total of 125 consecutive patients (96 males, 29 females; mean age 60 +/- 12 years) with left ventricular ejection fraction (LVEF)or = 35% and hemodynamically significant MR underwent DSE between 1999 and 2005. CR was defined as an increase in LVEF ofor = 10% during dobutamine infusion.Among 125 patients, 55 (43.0%) showed evidence of CR. Within five years after DSE, 24 patients (34.3%) in the CR- group and seven (12.7%) in the CR+ group had died or required heart transplantation (p0.01, log rank). After adjusting for age, baseline LVEF, NYHA class and moderate/severe tricuspid regurgitation (TR), CR remained an independent predictor of time to death or heart transplantation (HR 0.34; 95% CI: 0.15-0.76, p0.01). Improvement in the degree of MR was present at one year in 85.0% of CR+ patients, and in 62.5% of CR- patients (p = 0.03). An improvement of 5% in LVEF was noted in the CR+ group, compared to 0% in the CR- group (p = 0.04).In patients with advanced LVD and severe MR, CR detected by DSE was associated with significant reductions in the risk of death and heart transplantation.

To determine the proportion of patients with cardiomyopathy and mitral regurgitation of higher degree followed at tertiary care clinic who improve left ventricular function and or reduce mitral regurgitation grade. To determine clinical and echocardiographic predictors of improvement or deterioration. PATIENTS COHORT: Patients with cardiomyopathy and heart failure NYHA class II to IV, left ventricular ejection fraction less or equal to 40%. Total number of 42 patients met the criteria of moderate to severe mitral regurgitation, whose follow-up echocardiography was performed 3 to 12 months after the entry investigation and revealed improvement or deterioration of left ventricular function and mitral regurgitation grade.Mitral regurgitation grade improved in 10 patients (24%), left ventricular function improved in 9 (21%) patients. The combined improvement of left ventricular function and mitral regurgitation grade was assessed in 13 patients (30%), 29 patients did not manifest any improvement throughout the follow-up. Statistical analysis evaluating clinical and echocardiographic parameters revealed significant difference between group of improvement and group with deterioration in left atrial diameter at the baseline (p0.02). This result was influenced by gender distribution in the groups (decrease in statistical significance to p=0.067).Improvement of left ventricular function and mitral regurgitation grade was identified in 30% of the patients with cardiomyopathy and moderate to severe mitral regurgitation. No predictors of improvement or deterioration were identified among the clinical and echocardiographic variables.

The present case demonstrates the percutaneous implantation of a bioprosthetic valve in a patient with severe aortic stenosis. An 85-year-old man with significant comorbidities was determined to be at unacceptable risk with traditional surgical valve replacement. Percutaneous aortic valve implantation was performed, was successful and uncomplicated, with significant clinical and hemodynamic improvement. Currently, this procedure is an option only for symptomatic patients who are not appropriate candidates for surgical valve replacement.

Friedreich's ataxia is an autosomal recessive neurodegenerative disease. We report the case of a 34-year-old man with Friedreich's ataxia and dilated cardiomyopathy who underwent successful cardiac transplantation. To our knowledge, this is the first reported case of a heart transplantation for Friedreich's ataxia dilated cardiomyopathy.

Bleeding from gastrointestinal angiodysplasia in patients with aortic stenosis (AS), termed Heyde's syndrome, has been recognized for many years. Intestinal angiodysplasia (IA) and AS are chronic degenerative diseases that are often asymptomatic, with a higher prevalence in the population than is clinically apparent. The incidence of both conditions increases with age, and both are associated with traditional cardiovascular risk factors. Many studies suggest that there is an increased prevalence of IA in AS and vice versa, but there is wide variation between studies. Evidence is mounting that severe AS may cause Type 2 acquired von Willebrand's disease, also termed von Willebrand's syndrome. This involves loss of the large multimers, which are required to maintain hemostasis in high flow conditions, such as occur in angiodysplastic arteriovenous malformations. Heyde's syndrome appears to consist of bleeding from previously latent intestinal angiodysplasia as a result of this acquired hematological defect, which is associated with aortic stenosis. Treatment options include localization of angiodysplastic bleeding points with cauterization, but this is associated with a high recurrence rate. Aortic valve replacement has been shown to improve the hematological abnormalities, and this is paralleled by clinical improvements. Valve replacement appears to offer the best hope of long-term resolution of the bleeding, and should be considered in most cases, particularly in those in whom the AS is symptomatic. In those patients deemed unfit for surgery in whom no bleeding point can be identified, recurrent blood transfusions may offer some symptomatic relief.